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OPERATIVE SURGERY
ON THE DEAD BODY.
LONDOK
PSIXTED BT SPOTTIBWOOSB AND CO.
KXW>BTBSET SQUASE
A MANUAL
OP
OPERATIVE SURGERY
ON THE DEAD BODY.
• • •
• • • •
• •
• • • • • •
• • • • • •
.* •
# •
BY THOMAS SMITH, F.R.C.S.
BEMOIS^STBATOB OV AITATOMT AND OPBBATITE BUBOSBY AT ST. BABTHOLOMEW'S HOSPITAL :
SUBGBOir TO THE GBEAT NOBTHEBIT HOSPITAL.
WITH ILLUSTRATIONS.
LONDON :
LONGMAN, GREEN, LONGMAN, AND ROBERTS.
1859.
• • t •
•
••;
• •• •
• •
• • •
•• •••
• •
•••
*•* •
• . •
• • •
• •
•..: :
• • «
• •
• •
• •
» • 4
• # •
Sfo7
I86"7
PREFACE.
The requirements of the medical examining boards of this
country seem to imply that a practical knowledge of ope-
rative surgery should form an essential part of the edu-
cation of every surgeon, and that henceforth operative
dexterity should be acquired by practice on the dead body.
For this reason, the performance of surgical operations
on the subject has been introduced at most of our medical
schools ; and demonstrators have been appointed to
superintend and direct the studies of gentlemen in that
department.
The design of the present Manual is to give to students
a practical guide to the performance of operations on the
dead body, and to lighten the labours of teachers, by
enabling them to dispense with much oral instruction, and
to substitute the same kind of supervision that is ordinarily
exercised in the study of practical anatomy.
Only those operative measures are here treated of, which
can be advantageously practised on the dead body; and
these are arranged, as far as possible, in the order in which
▲ 3
\^ PREFACE.
they should be performed, — an order rendered necessary in
this country by the scarcity of anatomical subjects.
The Woodcuts which are here and there introduced in
the following pages were, with one or two exceptions, traced
from photographs taken from the dead body, during the
actual performance of the operations which they represent.
For the original photographs, as well as for their re-
production upon wood, the author is indebted to the
artistic skill of Mr. Godart,
Bedford Row, August 31st, 1859.
CONTENTS.
CHAPTER I.
INTRODUCTION.
The Selection of a Subject — ^Instruments. — Assistant. — A Table of Opera-
tions ....... Page 1
CHAP. n.
SOME OPERATIONS IN MINOB SUBQERT.
Methods of holding the Knife.— Sutures. — Plugging the Nostrils.— Cathe-
terisation of Eustachian Tube and Lachrymal Duct. — Mr. Bowman's
Operation on the Lachrymal Punctum. — Removal of the Eyeball. —
Artificial Anus ....... 4
CHAP. IIL
TENOTOMY.
Tenotomy. — General Remarks. — Operation for Strabismus. — Division of
the Stcmo Mastoid, Tibialis Anticus, Hamstring Tendons, Tendo Achillis,
Tiabilis Posticus . . . . . . .18
CHAP. IV.
LIGATURE OF ARTERIES.
General Rules for the Ligature of Arteries. — Instruments required, and their
respective uses. — Ligature of Arteries of Upper Extremity and Head and
Neck : radial, ulnar, brachial, axillary, subclavian, innominate, common ca-
rotid, external carotid, internal carotid, lingual, facial, temporal. — ^Arteries
of Abdomen and Lower Extremity : common iliac, internal iliac, external
iliac, femoral, anterior tibial, posterior tibial, peroneal, popliteal • 25
vm CONTENTS.
CHAP. V.
MEDIAN OPERATIONS.
Tracheotomy. — Laiyngotomy. — Pharyngotomy. — Lithotomy: (1) Lateral
Operation, (2) Mr. AUarton's Method, (3) Mr. Lloyd's Operation Page 51
CHAP. VI.
AMPUTATIONS OF THE UPPER EXTREMITT AND REMOVAL OF THE BREAST.
Amputations of the Upper Extremity. — General Remarks. — ^Various Me-
thods. — Instruments — Assistant. — Anatomy of Phalangeal Articula-
tions. — Amputations of the Phalanges at their various Joints: hy a palmar
Flap; by double Flaps. — Amputation of first, second, and third Fingers
at their metacarpal Joints. — Ditto of little Finger at the corresponding
Articulation. — Removal of the Fingers en masse at their metacarpal
Joints. — Amputation through third and fourth metacarpal Bones. —
Ditto through second and fifth. — Disarticulation of the Thumb at its
metacarpal Joint — Ditto of Thumb at its carpal Articulation. — Amputa-
tion of the Hand at its carpal Articulation, leaving the Thumb. — Of the
Hand at the Wrist- Joint by a single Flap ; by double Flaps. — Amputa-
tions of the Forearm : (1) Circular, (2) Flap, (3) Combined Method,
(4) Mr. Teale's Operation.— Upper Arm: (1) Circular, (2) Flap, (3)
combined Method, (4) Mr. Teale's Operation. — Removal of the Upper
Extremity at the Shoulder Joint by anterior and posterior Flaps ; by
upper and lower Flaps. — Removal of the Breast . . .60
CHAP. vn.
AMPUTATIONS OF THE LOWER EXTREMITT. — AMPUTATION OF THE PENIS. —
EXCISION OF THE TESTICLE.
Amputations of the Lower Extremity. — General Remarks on the Skeleton
of the Foot, and the Position of its various Articulations. — Amputation
of Phalanges of Toes — Ditto of Toes en. masse, — Lisfranc's Amputation.
— Chopart's. — Syme's. — Operation of M. Roux. — Pirogofi^s Amputation.
— Ordinary Method. — Dr. Eben Watson's Method. — Amputations of the
Leg : (1) Circular, (2) Flap, (3) Combined Method, (4) Mr. Teale's
Operation. — At the Knee- Joint, by (1) Anterior Flap, (2) By posterior
Flap.— Amputation of the Thigh : (1) Circular, (2) Flap, (3) Combined
Method, (4) Mr. Teale's Operation. — Amputation at the Hip- Joint. —
Removal of Penis. — Excision of Testicle . • . .89
^,
CONTENTS. IX
CHAP. VIIL
BESECTION OF ENTIRE BONES AND JOINTS.
Resection of Joints and entire Bones. — Phalanges of the Fingers. — Pha-
langeal Joints : (1) by lateral Incisions, (2) by a dorsal' Flap. — Meta-
carpal Bone of the Thumb. — Metacarpal Bone of little Finger. — Wrist
Joint: (1) by lateral Incisions, (2) a semilunar Flap, (3) Mr. Butcher's
Method. — Elbow Joint: (1) Liston*s Method, (2) H-shaped Incision,
(3) Langenbeck*s Operation. — Shoulder- Joint : (1) By a semilunar Flap,
(2) By a longitudinal Incision, (3) Stromeyer'a Method. — Excision of
the Lower Jaw.— Excision of the Upper Jaw. — Kesections of the Lower
Extremity. — Phalanges and Phalangeal Joints of the Toes. — Metatarsal
bone of great Toe. — ^Ankle- Joint. — Knee- Joint. — Hip- Joint . Page 115
CHAP. IX.
ON THE USE OF CERTAIN INSTBUMENTS.
Application of the Trephine to the Skull ; to long Bones. — Operation for
the Bemoval of a Sequestrum. — Application of the Stomach Pump ISO
r '
I
LIST OF ILLUSTRATIONS.
FIG. . PAGE
1. First Position of the Knife . ... 4
2. Second Position ..... ,4
3. Third Position . . . . . . .5
4. Manner of using the Knife and Director in conjunction . . .5
5. Position of the Knife in the larger Amputations . • .6
6. Eustachian Catheter . • . . . 10
7. Section of the Nasal Cavities . . . . .11
8. Catheter for the Lachrymal Duct . . . . ,12
9. View of the Lachrymal Canals, Sac, and Duct . . .13
10. Course of the Lingual Artery , . . . .40
11. Speculum used in Mr. Lloyd's Operation for Lithotomy . . 58
12. Forceps used in the same Operation . . . .59
13. Diagrammatic View of the Skeleton of the Hand, showing the
Position and Outline of its various Articulations . . 64
14. Amputation of the last Phalanx of a Finger . . .66
15. Side View of the Hand, showing the Outline of the Bones about
the Wrist . . . . . . .73
16. Manner of forming a Flap in Amputation of the Hand at the •
Carpo-Metacarpal Articulation . . . .74
17. Formation of a Palmar Flap in amputating at the Wrist- Joint . 76
18. The manner in which a Limb should be transfixed in forming a
Posterior Flap . . . .... 79
19. Manner of forming the Posterior Flap in Amputation at the
Shoulder-Joint . . • . . • .85
XU LIST OP ILLUSTRATIONS.
no. PAGB
20. Diyision of the external Rotator Muscles of the Humenis in the
same Operation . . . . . .86
21. Formation of the Anterior Flap in Amputation at the Shoulder*
Joint . . . . . . , .87
22. Diagrammatic View of the Foot, with an Outline tracing of its
Bones, the Direction of the Incisions in the Amputations about
the Parts being also shown . . . . .91
23. Method of tracing a Plantar Flap . . . . .94
24. Manner of dividing the Interosseous Ligaments, &c, in Lisfranc's
Operation . . . . . . .95
25. Manner of completing Lisfranc's and Chopart*s Operation , 96
26. Roux's Amputation . . . . . .99
27. Appearance of the Foot after this Operation . . .99
28. Dr. E. Watson's Method of performing Pirogoff *s Operation . 101
29. Manner of completing the same ..... 102
30. Appearance of the Wound after the Performance of Mr. Teale's
Amputation on the Leg • . . . .106
31. Appearance of the Stump, when the Flaps have been brought
together, after Mr. Teale's Amputation . . .107
32. Director used in the Practice of Resections . . .116
A MANUAL
OF
OPERATIVE SURGERY
ETC. ETC.
CHAPTER I.
INTRODUCTION.
The Selection of a Subject. — Instraments. — Assistant. — A Table of
Operations.
It rarely happens that the student of operative surgery in
this country has a choice of bodies for his purpose ; to
those who have such an opportunity, we would recommend
the selection of a male subject with a moderate amount of
fat about it. An emaciated body gives too low an idea
of the difficulties of ligaturing arteries on the living;
while its deficiency of subcutaneous tissue renders it diffi-
cult to provide sufficient material for the formation of
stumps in the practice of amputations. The subject should
be placed on a high and narrow table, such as dissecting-
rooms are generally furnished with.
To save subsequent trouble, the operator should at once
provide himself with those instruments which will suffice
for the performance of all the ordinary operations : these
instruments^ with others^ are contained in the regulation
B
2 TABLE OF OPERATIONS. [chap. t.
cases supplied to surgeons in Her Majesty's service ; an old
case of this description will be found most serviceable, as in
it the knives will have been worn down by successive sharp -
enings ; generally speaking, their blades are originally too
wide for some of the more difficult amputations. The ser-
vices of an assistant should be procured if possible ; and
we venture here to remind those who may officiate in that
capacity, that there is much to be learnt of the important
duties of their post from operations even on the dead body.
For the use of those who have but one subject at their
disposal, we append a table of operations that may all be
practised on a single body. This list, which can be modi-
fied at the discretion of the operator, will be found to con-
tain most of the operations in common use on the living,
and may serve to guide some in the economical use of
their materiaL
Table of Operations that can be performed upon one body,
arranged in the order in which they should be practised.
Incisions and sutures. Plugging the nares. Catheterism of Eustachian
tube and laciymal duct. Mr. Bowman's operation on the punctum and
lacrymal duct. Operations for strabismus. Excision of eyeballs. Te-
notomy. Division of sterno mastoid, tibialis anticus, hamstring tendons,
tibialis posticus, tendo Achillis. Artificial anus. Ligature of all the
arteries. Trephining. Tracheotomy. Laryngotomy. Pharyngotomy.
Lithotomy.
Amputations.
\,
Left side.
Phalanges at all their articulations.
Hand at carpal articulation, leav-
ing the thumb.
Bight side.
Distal phalanges of fingers and
thumb.
Fingers, en masse, at metacarpal
joint.
Hand at wrist joint.
On both sides.
Amputation at lower and upper third of forearm. Excision of elbow joints.
Amputation of upper arm at lower and middle thirds.
Kesection of the shoulder joint. | Amputation at the shoulder joint.
Amputation of the breasts.
CHAP. 1.]
TABLE OP OPERATIONS.
Right side.
Resection of the upper maxilla.
Amputation of the toes en masse
at metacarpal articulations.
Chopart's amputation.
Pirogoflfs ditto.
Leftside,
Resection of half the lower max-
illa.
Amputation of phalanges at their
various joints.
Lisfranc's amputation.
Syme's ditto.
Amputation of the legs in their middle and upper thirds. Resection of
both knee joints. Amputation of the thighs in their lower thirds.
Amputation at upper third of the Amputation at the hip joint,
thigh.
Amputation of the penis.
We would here, once for all state, that throughout the
following pages, wherever distances on the body are ex-
pressed by inches, it is presupposed that the subject is an
adult, and of average size and proportions. Again, when-
ever the expressions left-hand side or right-hand side are
employed, they always refer to the left, or right-hand side
of the body which is being operated upon.
B 2
6 6UTUBE9. [ckap. ii.
In figure 5, the knife, whicli in this case is alvrajs a
large one, is held in the full grasp of the hand ; it is thas
used in circular amputations, and in certiun other instances
to which we shall hereafter have occasion to refer.
Fig. 6.
Sutures are of various kinds, and are generally classified
as^l) interrupted; (2) unuiterrupted ; (3) twisted ; and
(4) quilled. The above-named modifications owe their
existence to the varying necessities of wounds, as the latter
occur in one or another part of the body. Thus the (1)
interrupted is used for wounds where absolute apposition of
every portion of their surface is either undesirable or unne-
cessary ; as in stumps after the removal of limbs ; in the
wounds left by the removal of tumours, or amputation of
the breast,
(2.) The uninterrupted or continuous best secures the
8 QUILLED suture; [chap. n.
To apply the ticisted suture, hare-lip pins, silk, or twine,
and the cutting wire pliers, are necessary,* The pins mnst
be carefully passed in, about half an inch from one edge of
the wound ; they must traverse it, and appear at the same
distance beyond its opposite margin.
When the requisite number of pins have been introdaeed,
a piece of silk or twine, about two feet long, is taken and
twisted over each in the form of the figure 8, so that the
point of crossing of the thread lies over the line of contact of
the edges of the wound. The thread may be secured by
tying its opposite ends together, and the pin may be cut
80 as to leave about half an inch projecting at either end,
beyond the thread.
The quilled suture is best applied with a strong curved
needle, fixed in a handle, and having an eye near its
point. This should be threaded with a double thread, and
iiaving been passed through the wound from side to side,
the looped end of the ligature is detached from the needle's
eye, and held with the left hand, while the needle is with-
drawn.
The needle should pierce, the skin an inch from the
edge of the wound, should traverse the deep parts, and
emerge at the same distance from its opposite margin.
When withdrawn, there will be a double thread remaining
in the wound having a loop at one extremity and two free
ends at the opposite. Through the loop or loops, if more
than one suture be used, a piece of gum catheter should
be passed and the thread drawn tight over it, while the
opposite ends are tied firmly over a similar piece of
catheter.
To maintain perfect apposition in the more superficial
• This suture is best applied to the wound in the face, left after the re-
moval of the upper jaw.
12
CATHETERISM OP NASAL DUCT. [chap. n.
Fig, 8.
^'ith an obstrnction^ which is generally felt after it has turned
rather more than a quarter of a circle. On turning the
handle more forcibly the point will be felt to slip over this,
the lower margin of the cartilaginous extremity of the
Eustachian tube. The catheter should now be pushed
onwards, outwards, and upwards very gently, until the
point is fairly in the cartilaginous extremity of the tube.
Its arrival at its proper destination may be ascertained by
rotation being now no longer possible, and by the ring
(fig. 6 a) at the bottom of the catheter being directed to-
wards the opposite angle of the mouth.
Figure 7 represents the catheter in position.
Sand shows the position of the orifice of the
Eustachian tube.
Catheterisation of the nasal duct from below.
— The lower orifice of the lacrymal duct may
be found at the anterior extremity of the in-
ferior turbinate bone, beneath its overhang-
ing border on the outer wall of the inferior
meatus of the nose (fig. 7).
This proceeding may be effected with such
an instrument as is delineated in the adjoin-
ing woodcut, or a soft silver probe may be
bent to the same shape (fig. 8).*
The head being in the same position as in
the preceding operation, the catheter may be
introduced with its concavity looking up-
wards, and its point directed to the lowest
part of the outer wall of the nostril. Being
in contact with the outer wall of the meatus,
it should be gently passed upwards with a
slight rotatory movement of its point, in an
'*' The instrament here figured is adapted for the duct of the right side.
16 ARTIFICIAL ANUS. [chap. n.
has become one of general operative surgery, and since it
can be advantageously practised on the dead body, we
shall describe the method of its performance, adopting Mr.
Dixon's modification of the new operation. A curved pair
of scissors, a blunt hook, forceps, and a spring-wire specu-
lum, are necessary for its performance. Having inserted
the spring speculum between the lids, make a circular
division of the conjunctiva with the scissors, about a quarter
of an inch behind the cornea. Raise the external rectus
muscle, and cut it across; an assistant should seize the
divided tendon and draw the eye inwards *, ** sliding one
blade of the scissors beneath the superior rectus and oblique
muscles, they are divided, and then the inferior rectus ; the
optic nerve is next snipped through, and the globe starts
forwards. Two or three strokes of the scissors divide the
internal rectus, vessels and bands of areolar tissue, and the
operation is complete."
Artificial anus. — The large intestine presents three
points where, without injury to the peritoneal sac, it can
be opened to give exit to its contents in cases of intestinal
obstruction. An artificial anus may be formed in the
coecum or ascending colon; but the most favourable situa-
tion for this aperture is in the left lumbar region over the
descending colon. The portion of the intestine here within
reach, is limited above by the lower border of the kidney,
and below by the crest of the ilium ; at this point the gut
lies upon the aponeurosis of the transversalis muscle, to the
outer side of the quadratus lumborum, and behind the peri-
toneal sac and mass of the small intestines.
The subject being turned over on its face, the loins may
be rendered prominent by placing a block or two beneath
the belly. Retractors, scalpel, forceps, sutures, and direc-
tor, are required.
* Dixon, Diseases of the Eye, page 393, 2iid edition.
CHAP. nO AMUSSAT'S OPERATION. 17
Amussat^s operation, — A transverse incision sl^ould be
made an inch above the posterior part of the crest of the
ilium, beginning at the external border of the erector spinas,
and extending outwards for three or four inches ; the skin
and superficial fascia being divided, the latissimus dorsi,
and perhaps a portion of the external oblique muscle, will
come into view : these, together with the fascia of the in-
ternal oblique and transversalis, should be divided on the
director, and the loose subperitoneal tissue will be reached ;
in this, search for the intestine with the point of the direc-
tor, and having found it, draw it out of the wound to a
small extent; its edges being transfixed by sutures and
united to the integuments, it may be opened at its most
prominent part, and the operation will be complete.
TJie ascending colon may be exposed by an incision made
in the right loin, in the same manner as described above.
To open the cwcum, a w^dund should be made in the abdo-
minal wall about three inches in extent, commencing an
inch above the right anterior superior spine of the ilium,
and extending downwards in the direction of Poupart's
ligament.
18 DIVISION OF TENDONS. [chap, m.
CHAP. in.
TENOTOMY.
Tenotomy. — General Remarks. — Operation for. Strabismus. — ^Division of the
Stemo Mastoid, Tibialis Anticas, Hamnstring Tendons, Tendo Acbillis,
Tiabilis Posticus.
Tenotomy is an operation which in all practicable cases
must be performed subcutaneously ; it is with this object
that a series of knives have been invented^ allowing of the
division of tendons with but little exposure of the wound
to the external air.
The only instruments required for the performance of the
following operations, with the exception of that for strabis-
mus, are a sharp-pointed and a blunt-pointed tenotomy knife.
The former is used for. perforating the skin over tendons,
and for dividing tendons themselves where there are no
important parts within reach of injury. This knife is held
as a pen * ; it should penetrate the skin on the flat, that is
with the flat of the blade parallel to the line of the tendon.
When in contact with the tendon, its edge should be turned
at right angles to the former, and in this position the tendon
should be divided. The blunt- pointed knife is for dividing
tendons, such as those of the tibial muscles, where there
are important parts in the neighbourhood which are ex-
posed to injury ; it is held in the haiid and used in the
same manner as the sharp-pointed knife.
In dividing a tendon, the end of the thumb should be
♦ Page 4, fig. 1.
CHAP, m.] OPERATION FOR STRABISMUS. 19
placed over it while the knife is beneath it. In this manner
the operator can ascertain when the division of the tendon
is nearly completed, and can thus exercise greater care to
guard the skin from injury as the knife approaches the sur-
face.
The duties of an assistant in this operation are, firstly,
to put the tendon on the stretch, to enable the operator to
ascertain its exact position ; secondly, to relax it, allowing
of the insertion and adjustment of the knife ; thirdly, to
tighten the tendon whjle the operator divides it. The com-
pletion of the section can be ascertained by the sudden
relaxation of the parts, by the creaking of the tendinous
fibres under the knife, and often by the obvious gap
remaining in the course of the tendon from the retraction
of its ends.
The following operations should be undertaken while the
body is yet fresh, either before or immediately after the
operations on the arteries.
Division of the internal rectus muscle of the eye. — We
have selected this muscle for the description of the opera-
tion for strabismus, as its division represents the proceeding
usually required in that affection.
A spring-wire speculum, a pair of blunt-pointed small
scissors, two pair of forceps, the one broad-pointed for
holding the eye, the other being ordinary dissecting
forceps, and a blunt hook, comprise the list of instruments
necessary for the operation.
The operator should stand facing the subject, and the
assistant behind the head, facing the operator. Having
introduced the wire speculum between the lids, the assist-
ant should, with the broad-pointed forceps, grasp a fold of
the conjunctiva on the outer aspect of the eye and rotate
the ball outwards so as to expose the inner part of the
white of the eye. Let the operator now pinch up with the
c 2
20 OPERATION FOR STRABISMUS. [chap. hi.
forceps the conjunctiva, about one-third of an inch to the
inner side of the cornea, and below the situation of the
tendon of the inner rectus muscle; this fold of con-
junctiva should be divided to the extent of about a quarter
of an inch, in a direction radiating from the circumference
of the cornea, and parallel with the lower border of the
rectus. Having cut through the subconjunctival tissue
in the same direction, pass the blunt hook into the wound,
gliding its extremity on the eyeball, downwards, back-
wards, and lastly upwards, so as to pass beneath the lower
border of the tendon of the rectus. Lift the tendon up-
wards, away from the ball of the eye, and pass the
scissors down the hook into the wound, and divide the
tendon beneath the conjunctiva by a series of snips, cutting
from below upwards. The hook may be again inserted,
and any remaining fibres caught up and divided in a
similar manner.
The difficulty in this operation is to pass the point of the
hook beneath the lower border of the muscle ; this may
be obviated by passing the hook some distance backwards
before attempting to catch the tendon.
The foregoing proceeding may be applied to any of the
recti muscles of the eye; the incision in the conjunctiva
being made in each case, in a direction radiating from the
circumference of the cornea.
Division of the stemo mastoid, — This operation is under-
taken for the cure of certain cases of wry neck, and is
generally put in practice on the lower third of the muscle,
which at this part is covered by the skin, platysma, cervi-
cal fasciae, and its own sheath ; it is crossed obliquely from
within outwards and above downwards by the external
jugular vein, though generally at a point higher in the
neck than that selected for its division. The operation
may be performed in two ways; for the first method, a
22 . TIBIALIS AXTICUS AND HAMSTRINGS. [cnAP. in.
the posterior surface of the muscle, and not allow it to
include any of the deeper structures.
Division of the tendon of the tibialis anticus. — The spot
which is usually selected for division of this tendon for club
foot, is just in front of the ankle joint where the tendon is
most prominent. Here it lies on the tibia, in the inner-
most of the sheaths in front of the ankle, having the an-
terior tibial artery to its outer side but separated from it
by the extensor proprius pollicis.
The foot teing abducted and extended by an assistant,
the operator, standing on the opposite side of the. leg to
that of the tendon which he wishes to divide, and facing
the patient for the muscle of the right side *, should feel
for the prominence of the tendon with the forefinger of the
left hand ; keeping his finger on this spot, he should make
an incision with the sharp-pointed knife, straight down to
the inner side of the tendon, the blade of the scalpel being
parallel to the latter; let him now introduce the blunt-
pointed knife, and having passed it on the flat beneath the
tendon, let him turn its edge and divide the tendon at a
right angle, while the assistant puts the parts on the
stretch. The usual precautions must be adopted for
guarding the integuments from injury.
The body being turned on its face, the remainder of the
operations enumerated at the commencement of this chapter
can be performed.
Section of the hamstring tendons, — The biceps may be
divided where it lies in the outer fold of the popliteal
space, external to and overlapping the peroneal nerve.
The operator should stand on the same side of the limb as
the tendon which he is about to divide, and with his back.
♦ His back being towards the body in operating on the muscle of the
opposite side.
24 TIBIALIS POSTICUS. [chap. m.
parts ; the assistant in the meantime putting the foot in a
position of flexion to stretch the tendon.
It is customary with some operators to introduce the
scalpel on the dorsal surface of this tendon^ and this is best
effected by pinching up the skin on the back of the heel,
while the parts are relaxed, and subsequently cutting
from the superficial towards the deeper aspect of the
limb.
Division of the tibialis posticus. — The tendon of this
muscle is found behind the inner ankle, in a groove on the
tibia, and nearer to the inner malleolus than the other
tendons ; it is separated from the posterior tibial artery and
nerve, which lie behind it, or nefirer to the os calcis, by the
flexor longus digitorum. The point usually selected for its
division is at a spot about an inch and a half above the
inner malleolus, immediately behind which point of bone
the tendon is found. The foot being flexed and placed
in a position of forced abduction, the line of the tendon
should be felt for, and having been determined, the forefinger
of the left hand should be placed on the spot, and retained
there during the operation. The operator, standing on the
opposite side of the leg to that of the tendon, should intro-
duce the sharp-pointed tenotomy knife to its inner side, and
thrust it quite down to the bone ; having substituted a
blunt-pointed knife, the tendon may be divided from within
outwards, taking care not to pass over it, as it lies in its
groove on the bone.
CHAP, iv.j GENERAL RULES. 25
CHAP. IV.
LIGATURE OF ARTERIES.
General Rales for the Ligature of Arteries. — Instruments required and their
respective use. — Ligature of Arteries of Upper JExtremity and Head and
Neck : radial, ulnar, brachial, axillary, subclavian, innominate, common
carotid, external carotid, internal carotid, lingual, facial, temporal. — Ar-
teries of Abdomen and Lower Extremity : common iliac, internal iliac,
external iliac, femoral, anterior tibial, posterior tibial, peroneal, popliteal.
To expose the large vessels of the body with certainty, it
is necessary not only to know their relational anatomy as
regards the parts with which they are in immediate
contact; but accurately to ascertain their position, and the
direction of their course with respect to the external con-
formation and outline of the parts of the body in which
they are found. With this object it is usual to take as
guides and landmarks to the position of subjacent vessels,
either the outline of some muscle, or imaginary lines drawn
from one point to another. In all cases where the external
conformation of the limb admits of it, we have chosen pro-
minent points of bone as landmarks ; as these are more
constant in their relative positions, and more easily disco-
vered than the outlines of muscles, which latter are too
liable to be obscured by fat, or rendered indistinct from
other causes.
The subject being placed on its back on a narrow table,
the operator may prepare to perform the ligature of all the
principal arteries of the body. He will require a scalpel.
26 THE USE OF THE KNIFE. [chap. iv.
a pair of dissecting forceps, a grooved steel director, and an
aneurism needle. The scalpel should be from two to three
inches in length in the blade. The groove in the director
should run quite to its extremity, and leave no cul de sac in
which the point of the knife can catch.
As there are certain general rules which must be
followed in attempting the ligature of all arteries, we
propose to notice them here, to avoid subsequent repe-
tition.
The knife is for cutting, and for this alone, it should not
be used for scraping or scratching at the sheath of a vessel ;
it had best be laid aside so soon as the arterv comes into
view. When the direction and length of incision have
been determined, the integuments should be slightly-
stretched by the middle finger and thumb of the left
hand, placed on either side of the line of incision. The
scalpel should be held as a pen in writing (fig. 1, page 4),
and on its first contact with the skin should be held at the
same inclination to the surface as a pen ; as the integuments
.are divided, its position should gradually become vertical,
so that on the completion of the incision it may be perpen-
dicular to the surface. When practicable the first incision
is always made immediately over and parallel to the course
of the vessel to be tied : it should not divide more than the
integuments. Each successive cut ought to be of precisely
the same extent as the preceding.
The use of the forceps is obvious, but it may be well to
remark that they are not to be applied directly to the artery
itself, or to any large nerve or vessel that may be exposed
during the operation.
The steel director is used for dividing fasciae upon, for se-
parating muscular interspaces, and for detaching the artery
from its sheath ; it is of great service in all those cases in
which a silver knife is used by many operators. In ex-
CHAP. IV.] THE USE OF THE DIRECTOR. 27
posing a vessel, as a general rule, intervening fasciaa are
divided on the director*, which is inserted through a small
hole, made by pinching up the parts with the forceps, and
cutting with the blade of the knife on the flat. Muscular
interspaoes, if large, are most conveniently separated with
the forefingers, contiguous tendons with the point of the
director.
To free the vessel from its sheath, a small hole must be
made in the latter, as in opening a fdscia; the margins
of this aperture being alternately seized with the forceps,
the point of the director should be insinuated between
them and the coats of the vessel. This separation ought
to include the whole circumference of the artery, but as
little as possible of its length.
An aneurism needle, with a very large curve, will be
found most convenient on the dead body ; besides its ob-
vious purpose, it may, in its passage round the vessel,
separate any remaining adhesion between this and its
sheath. In passing the ligature, the point of the needle
is generally inserted between the vessel and any neigh-
bouring structure there may be a risk of including in the
ligature. Having withdrawn the needle and left the liga-
ture in position, a single knot should first be formed, and
the ends of the silk be grasped by the thumbs and fore-
fingers passed down as near to the vessel as possible ; the
knot may now be drawn tight, and secured by a second,
tied over it. It is essential to pass the fingers down to the
vessel before tightening the ligature, in order to avoid
disturbing its connections, and also the more accurately to
appreciate the amount of force applied.
We shall describe the operations for ligature of the various
arteries in the order in which they should be practised on
♦ Fig. 4, page 5.
28 LIGATURE OF THE RADIAL. [chap. iv.
the subject, and shall omit those which rarely, if ever, come
under our notice on the living body.
Tlie radial artery. — The course of this vessel will be suf-
ficiently accurately indicated, by a line drawn from midway
between the condyles of the humerus to a point, half an inch
internal to the styloid process of the radius at the wrist. In
the upper third of its course, it lies between and is some-
w^hat overlapped by the supinator longus on the outer side,
and the pronator 'teres on the inner side ; but lower down
in the forearm it is found more superficially, between the
tendons of the flexor carpis radialis on the inner, and
the supinator longus on the outer side. In the whole
of its course under consideration, this vessel is found in
the outermost intermuscular space of the front of the fore-
arm, and is covered by nothing but the integuments and
deep fascia, or rather it is only necessary to divide these to
expose the artery.
A ligature may be applied to this vessel in any part of
its course: we propose to tie it in its lower and upper
thirds.
Lower third. — An incision should be made in the direc-
tion of the line above indicated, commencing three inches
above the wrist, and extending downwards for two inches.
This should fall between the tendons of the flexor carpi
radialis and the supinator longus; immediately beneath
the integuments the superficial radial vein is usually found.
Pushing this aside, divide the deep fascia on the director,
and the artery will come into view, surrounded by its venae
comites and an imperfect sheath, both of which must be
separated with the point of the director, and the ligature
passed.
Upper third. — To tie the artery in its upper third, make
an incision three inches long in the course of the vessel,
commencing two inches below the bend of the elbow and
CHAP. IV.] LIGATURE OF THE UIAAR. 29
running towards the wrist, search for the most external
white line in the deep fascia; this marks the intermuscular
space in which lies the artery. Having opened the fascia
at this spot, use the finger or the director to separate the
muscles, clear the artery from its connections, and apply
the ligature from witliout inwards, to avoid the possibility
of including the radial nerve.
The ulnar artery y in the part of its course with which
we are concerned, extends with a slight curve from the
middle of the bend of the elbow to the radial side of the
pisiform bone. In the first part of its course it runs
obliquely ; here it passes beneath the muscles coming from
the inner condyle, and above the flexor profundus. In the
lower two thirds of the forearm, it is found on the latter
muscle, and overlapped by the flexor carpi ulnaris; its
nerve joins it about the middle of the arm, and continues
with it on the ulnar side as far as the wrist Practically,
this artery can only be tied in the lower two thirds of its
course ; to expose it between the flexor sublimis and flexor
profundus digitorum, in the upper part of the forearm,
would necessitate a most unwarrantable division of soft
parts. It must be approached through the innermost
intermuscular space of the front of the forearm, that is
between the flexor carpi ulnaris and flexor sublimis digi-
torum.
To expose the artery in its lower thirds an incision should
be made in the line of the course of the vessel, commencing
three inches above the wrist, immediately external to the
tendon of the flexor carpi ulnaris, and extending down-
wards parallel to that tendon for rather more than two
inches ; care should be taken to avoid injuring the super-
ficial ulnar vein. By dividing the muscular fascia, the
border of the tendon of the flexor carpi ulnaris will come
into view, beneath which the artery lies. The vessel being
so LIGATURE OF THE BRACHUL. [chap. iv.
cleared, the aneurism needle should be passed from its ulnar
to its radial side, to avoid the chance of including the ulnar
nerve in the ligature. The operation is much facilitated
by bending the wrist directly the above-mentioned tendon
comes into view, as this permits the tendon to be drawn
inwards without diflBculty.
Ulnar artery with middle third. — Here the artery lies
more- deeply, and is approached by making an incision two
or three inches long, to the radial side of the inner margin
of the forearm, in the direction of the vessel : beneath this
spot the white line which marks the separation between the
flexor carpi ulnaris and flexor sublimis must be sought,
and here the muscular fascia must be divided. After
separating these muscles, the ulnar nerve will probably
first come into view ; and to its radial side, overlapped by
the flexor sublimis, will be found the artery.
The brachial arf^r^y, ex tending from the lower border of the
tendon of the teres major to the bend of the elbow, is covered,
except at the last-mentioned place, only by the integuments
and deep fascia ; at the elbow it has in addition a covering
from the tendon of the biceps, generally termed the semi-
lunar fascia. A line, drawn from the inner border of the
coraco brachialis to the middle of the bend of the elbow,
would indicate its course ; or the inner border of the
biceps muscle sufficiently nearly represents it. The vessel
lies for some distance on the triceps, and for a short space,
just above the elbow on the brachialis anticus ; to its outer
side in the upper third of the arm, is the coraco brachialis,
and below this point the biceps. Near the commencement
of the artery, the median nerve crosses it in front, and runs
on its inner side to the bend of the elbow. It is worthy
of remark that the basilic vein lies over the vessel in the
whole of its course ; it may be found either in the sub-
cutaneous tissue, or beneath the deep fascia. We pro-
32 COUESE OF THE AXILLAET [chap. iv.
major muscle ; it presents two points at which a hgature can
be applied,— viz., immediately below the clavicle, and at the
lower part of the axilla. It is covered in its -whole course
by the pectoralis major, is crossed about its middle by the
pectoralis minor, has the axillary vein to its thoracic side
and in front of it, with the brachial plexus at first above,
and subsequently surrounding it more or less.
Below the clavicle the vessel is covered by the integu-
ments, platysma, pectoralis major, and deep fascia, the fascia
of the pectoral muscle, and the costo-coracoid membrane ;
it lies deeply, between the brachial plexus above, and the
axillary vein below ; is crossed from above downwards by
the two anterior thoracic nerves, and obliquely from with-
out inwards by the cephalic vein ; between it and the first
intercostal space runs the long thoracic nerve. In the
lower part of the axilla the artery is generally covered by
the confluence of the basilic vein with the venae comites,
and has on its inner side the ulnar and two internal cuta-
neous nerves, and often ope root of the median. On its
outer or acromial side is the coraco brachialis, the external
cutaneous nerve, and sometimes the outer root of the me-
dian nerve. Occasionally the two roots of the median
unite in front of the artery at this spot From what is
stated above, it is evident that the ligature of the axillary
trunk is no easy task : it may be well to mention that in the
succeeding operations, the knife should be used as little as
possible, the point of the director being put in requisition
for the separation of the deeper parts.
Ligature in the lower part of the axilla. — The arm should
be raised above the head, so as to expose the cavity of the
axilla, and an incision made along the inner border of the
coraco brachialis, in the direction of that muscle. The ax-
illary and deep fasci38 should he divided on the director, and
the knife laid aside : the artery should now be sought and
^0 ' POPLITEAL AETERT. [chap. iv.
attachment, and lay bare the deep muscular fascia ; open it
and search for the vessel just behind the posterior border
of the fibula. The ligature may be passed from either side,
as there is no accompanying nerve.
The subject being turned over on its face, the operator
should turn his attention to the popliteal artery.
This vessel, entering the space of the same name through
the tendon of the adductor magnus, ends at the lower
border of the popliteus. It does not pursue its course
parallel with the long axis of the limb, but inclines sliglitly
from within outwards until it ends exactly in the middle
line of the popliteal space. Its course is expressed by a
line drawn to the centre of the popliteal space, from a
point four inches higher up the limb -and an inch to the
inner side of the middle line. The artery lies on the back
of the femur, the posterior ligament of the knee joint, and
the popliteus muscle successively ; to its outer side and par-
tially overlapping it is the popliteal vein, and still more
external the popliteal nerve. The wound for exposing the
vessel should be nearly four inches long, and should be
slightly oblique in its direction from within outwards,
terminating midway between the condyles of the femur.
Care should be taken in making the first incision not
to injure the posterior saphena vein. On dividing the
integuments and fascia, the popliteal nerve will generally
be seen ; it should be drawn to the outer side, and the
vessel sought for to its inner side, where it will be found
lying deep in the popliteal space with its vein external
to it. Separate the artery and vein, and pass the ligature
from without inwards.
b
60 AMPUTATIONS — GENERAL REMARKS. [chap. vi.
CHAP. VI.
AMPUTATIONS OP THE UPPER EXTREMITY AND
REMOVAL OF THE BREAST.
Amputations of the upper extremity. — General remarks. — ^Various me-
thods. — Instruments. — ^Assistant. — Anatomy of Phalangeal articulations.
— ^Amputation of the phalanges at their various joints : by a palmar flap;
by double flaps. — Amputation of first, second, and third fingers at their
metacarpal joints. — Ditto of little finger at the corresponding articulation.
— Removal of the fingers en masse at their metacarpal joints. — Amputa-
tion through third and fourth metacarpal bones. — Ditto through second
and fifth. — Disarticulation of the thumb at its metacarpal joint. — Ditto
of thumb at its carpal articulation. — Amputation of the hand at its carpal
articulation, leaving the thumb.^Of the hand at the wrist-joint by a sin-
gle flap; by double flaps. — Amputations of the forearm ; (1) circular, (2)
flaps, (3) combined method, (4) Teale's operation. — Upper arm : (1) cir-
cular, (2) flap, (3) combined method, (4) Teale's operation. — Removal of
the upper extremity at the shoulder joint by anterior and posterior flaps ;
by upper and lower flaps. — ^Removal of the brens^
Amputations are generally classed as those of continuity,
or amputations proper, and those of contiguity, or dis-
articulations. The object in view in all methods of ampu-
tation is the same, — namely, after the removal of the part,
to secure a suitable and sufficient covering for the end of
the bone, to avoid adhesion between the latter and the
cicatrix of the integument ; to divide the large nerves and
blood-vessels transversely, and to leave their cut ends in a
part of the stump little exposed to pressure. Stumps are
either formed of integuments alone *, or of muscular tissue
* By integuments we mean both skin and subcutaneous tissue.
64 ARTICULATION OP THE PHALAlfGES. [chap. vi.
corresponding knuckle. Having noticed the sitnation of
tbe articulations, we would recommend the operator to
observe their precise shape ; and for this we would refer
him to £g. 13, where he will 6nd the line of the two more
Fig. 13.
distant phalangeal joints to be concave from side to aide,
with the concavitj directed towards the ends of the fingers.
He may also notice that the line of articulation runs parallel
to and is the same shape as the inferior margin of the nail
84 AMPUTATION AT THE SHOULDER- JOINT, [chap. vi.
external in position, and care should be taken to include the
brachial vessels in the posterior or short flap.
Amputation of the arm at the shoulder-joint. — The plans
adopted for disarticulating the humerus at this joint are
very numerous, though many only differ from each other
in inessential particulars. We shall only describe (a) the
operation by an upper and a lower flap ; and (6) that by an
anterior and posterior flap.
(a) The body, being raised by two or tliree blocks placed
beneath the shoulders, should be brought towards the edge
of the table, the operator should stand outside the limb,
and the assistant behind the shoulder. In this as in all
operations for disarticulation at the shoulder-joint, an am-
putating knife of moderate dimensions will be found more
commodious than the formidable weapon generally figured
in books. The operator grasping the deltoid in his left
hand, and raising it, should thrust his knife beneath it,
transfixing the limb just below the acromion, and on its
upper and out^r aspect ; the knife should graze the
neck of the humerus, and in cutting its way out below
should form a flap with a rounded border, about four
inches in length ; this the assistant raises and retracts.
The head of the bone being now exposed, the heel of the
knife should be laid on the upper aspect of the anatomical
neck, and the muscles inserted into the greater tuberosity
divided, while the bone is rotated inwards ; the joint being
opened on its upper and outer aspect, the subscapularis
should be divided, the knife passed behind the neck of the
bone, and with one sweep be made to cut its way out in
the axilla, forming an inferior flap similar to the first. In
the living body the axillary artery should be controlled by
pressure made against the first rib just external to the
scalenus anticus ; after the operation, its divided end will
be found near the inner angle of junction between the
88 REMOVAL OF THE BREAST. [chap. vi.
more firmly in the second or third position (p. 4). The ope-
rator should stand on the same side of the body as that of the
breast to be removed, the corresponding arm of the subject
being carried out from the side ; he should make two semi-
elliptical incisions, having their long axes parallel with that
of the ribs, and including between them, the nipple and a suf-
ficiency of skin to allow of the removal of the gland through
the wound. These incisions should meet one another beyond
the axillary and sternal borders of the breast respectively.
For the right breast the upper incision should be first made,
commencing from the axilla; it should extend pretty deeply
into the subcutaneous fat; it should not cut quite vertically
through the skin, but rather in an upward direction, so as
to pass over the convex surface of the breast without
injuring the glandular structure. The lower incision
should next be made from the sternum towards the axilla,
and this also should be adapted somewhat to the convexity
of the breast. While the assistant grasps the gland and
draws it upwards, the operator should seize the skin at the
lower edge of the wound and dissect it off the breast until
the lower border of the gland comes into view ; lifting up
this and dissecting between it and the pectoral muscle,
he must completely undermine the gland. Taking the
breast into his own hand, and drawing it downwards while
the assistant raises the upper edge of the wound, the
operator should dissect away the coverings from the upper
part of the gland until he reaches its upper boundary,
when the separation of the breast will be complete, and the
operation concluded.
CHAP. VII.] POSITION OP THE TARSAL ARTICULATIONS. 91
OS calcis, about an inch below the malleolus, and generally
called the peroneal tubercle (fig. 22) ; from an inch to an
inch and a half farther on, he will encounter a well marked
bony prominence, constituting the proximal end of the
Fig. 22.
metatarsal bone of the little toe (fig. 22). The articulation
between the calcis and cuboid is situated about half an inch
in front of the peroneal tubercle, or it may be said to be
midway between that point and the prominence of the fifth
metatarsal bone.
The joint between the cuboid and fifth metatarsal bone lies
immediately behind the projecting extremity of the latter.
114 KEMOVAL OF THE TESTICLE. [chap. vn.
cut edge of the common integuments of the part. The
urethra before being sewn to the external skin should be
split into three divisions, to allow of its orifice being spread
out.
Castration. — To remove the testicle, the body should be
drawn to the edge of the table and the thighs separated,
while the operator, standing between them and facing the
abdomen, should grasp the hinder part of the scrotum with
his left hand, pinching it up, and thus throwing forward
the testicle and tightening the integuments over it and the
spermatic cord. Let him now make a nearly vertical inci-
sion, commencing at the external abdominal ring, extending
downwards to the lower part of the testicle, and laying bare
the gland ; forcing the latter forward by tightening the
grasp of his left hand, with the point of the scalpel the ope-
rator should dissect off the coverings of the cord at that
point where it leaves the testicle. When completely iso-
lated, this part may be included in a strong ligature, or
held by an instrument for the purpose, to prevent the re-
traction of its upper end. It should now be divided just
above the epididymis, its lower end grasped by the ope-
rator, and the testicle dissected out from above downwards,
while the scrotum is held aside by an assistant. The su-
perficial pudic artery is divided in this operation in making
the first incision, and in the living body generally requires
ligature ; in the section of the cord the spermatic, deferen-
tial, and cremasteric vessels are divided.
118 KESECTION OP THE WRIST JOINT. [chap. vili.
divide its attachments to the first phalanx^ twisting the
bone hither and thither to facilitate this process.
The fifth metacarpal hone may be resected in a similar
manner by an incision made along its ulnar border.
Resection of iJie wrist joint, — This operation^ owing to
the complexity of the articulation on which it is practised, is
necessarily imperfect in its nature ; that is, the opposed arti-
cular surfaces cannot be completely removed, and thus the
most favourable conditions for resection cannot be fulfilled.
The principal methods of performing the operation are
three : Istly, by lateral longitudinal incisions running along
the subcutaneous margins of the radius and ulna respec-
tively, leaving all the tendons uninjured ; 2ndly, by forming
a semilunar flap on the back of the joint, dividing all the
extensor tendons; and, 3rdly, Mr. Butcher's method, in
which the extensor tendons of the thumb are left intact.
The first plan is certainly practicable on the dead
body, but must be quite impossible in many cases on the
living where the joint requires removal. It is effected
by making two lateral incisions, one on either side the
joint, along the subcutaneous borders of the radius and
ulna respectively ; commencing half an inch in advance of
each styloid process, and extending up the forearm for
three inches or more. The soft parts should first be care-
fully dissected from the ulna until the director can be
passed around the bone and its groove turned upwards ; this
being effected the bone may be sawn upon the director
about an inch above the wrist, the lower fragment grasped
with the forceps and disarticulated with the point of the
knife. The radius should now be freed from the tendons
which surround it, by dissecting chiefly from its outer to
its inner border; the director being passed around it to
keep these aside, the bone may be sawn off and separated,
as in the case of the ulna.
(2.) A semilunar flap is cut from the back of the wrist.
122 EXCISION OP THE LOWER JAW. [chap. Tm.
from within outwards^ over the upper side of the joint:
now rotate the bone in the opposite direction^ and divide
the tendon of the subscapularis^ at the same time completing
the division of the capsule of the joint Pass the director
round the neck of the bone to protect the soft parts^ and
saw off the head.
(2.) The plan which generally goes by the name of Lan-
genbeck's operation, is that which he made use of during
the Schleswig Holstein war. Its object is to save the long
tendon of the biceps, and to avoid the transverse division
of the fibres of the deltoid.
A longitudinal incision is made, commencing at the most
prominent point of the acromion, and extending downwards
for four or five inches. This should fall just over the
bicipital groove, and should divide all the structures down
to the bone ; the tendon of the biceps being disengaged
from its groove, and, together with the edges of the wound,
being held aside by the assistant, the operation may be
completed as in the last discussed method, though it will
be found that its execution is more difficult.
(3.) Stromeyer makes use of a semicircular incision,
commencing at the posterior edge of the acromion, and
extending downwards and outwards for three inches or
more, having its concavity directed forwards. Tiie joint
is thus freely opened on its upper and posterior aspect, the
tendon of the biceps can be preserved, as in the preceding
operation, and a dependent aperture is left for the secre-
tions of the wound.
Removal of the loicer jaw, — We proceed to describe this
operation before treating of excision of the superior maxil-
lary bone, as its performance does not prevent the subse-
quent execution of that operation. With care, on the
same face both sides of the inferior maxilla may be re-
moved as well as both superior maxillary bones.
128 RESECTION OP THE HIP JOINT. [chap. vm.
limb. As he does so, the operator should sever all remaining
ligamentous connections between the bones^ being especially
careful during the division of the posterior ligament. He
should now pass the knife around the lower end of the
femur, just at that part where he wishes to apply the saw;
with this he may remove a portion of the bone^ cutting
from its anterior towards its posterior surface, and taking
care that the section be at right angles to the long axis of
the shaft. Any connection that this portion of bone may
still retain after the application of the saw should be divided
carefully with the scalpel. A thin shell of bone being re-
moved in the same manner and with the same precautions
from the extremity of the tibia, the operation will be com-
plete. The patella is generally removed with the portion
of the femur that is taken away. No blood-vessels of any
consequence should be divided.
Resection of the hip-joint, — The operation which passes by
this name consists in the removal of the head of the femur:
it may be well to practise it on the dead body, though on
the living, the head of the bone is in most cases dislocated by
disease previous to being subject to operation ; the ordinary
instruments for resection are suflScient for this proceeding.
The body being turned over towards the opposite side,
and the thigh slightly flexed, the operator should place
himself by the side of the joint he is about to excise, and
make a curved incision on the outer side of the joint, em-
bracing in its concavity and passmg close behind, the most
prominent part of the great trochanter. This incision
should be from four to five inches in length, and should
commence between the anterior superior spine of the ilium
and the top of the trochanter major. The glutei mus-
cles being divided, and the external rotator muscles, the
capsule may be opened from behind, while the limb is
forcibly flexed and adducted by an assistant; this will
CHAP, vm] RESECTION OF THE HIP-JOINT. 120
being the ligamentum teres within reach, which when cut,
will allow of the dislocation of the head of the bone. The
director being passed around its neck, the head may be
removed with the saw, and the operation will be complete.
There are various methods of dividing the soft parts
over this joint; but whatever plan be pursued, it must be
put in practice over the posterior and outer part of the
articulation, and the incision, of whatever form, should fall
between the trochanter and the great sciatic nerve.
130
TREPHINING THE SKULL, [chap. ix.
CHAP. IX.
ON TllE USE OP CERTAIN INSTRUMENTS.
Application of the Trephine to the Skull.— To long Bones. — Operation
for the Removal of a Sequestrum.— The Stomach-pump.
The trephine^ be sides its more obvious purpose for removing
portions of the bones of the vault of the skull, is used for
exploring the cancellous extremities of long bones, and for
exposing the medullary cavity of their shafts.
Far trephining the skull sl small scalpel, a probe, and an
elevator are required in addition to the trephine itself. In
applying this instrument to the cranium on the dead body,
a precaution should be adopted which cannot always be
followed on the living — namely, that of selecting a spot for
its application out of the course of the trunk of the middle
meningeal artery, and clear of the longitudinal or lateral
sinuses ; as a general rule, the immediate neighbourhood
of the sutures should be avoided. A spot having been
selected, the scalp should be cleanly reflected from the bone
over the parts, either by a semilunar, crucial, or A -shaped
incision ; the operator, standing well above the part, should
project and fix the central pin of the trephine about a lint
beyond its serrated edge, and apply the instrument to the
bone with an alternating semirotatory movement, until it
has cut for itself a groove of sufficient depth to obviate the
chance of slipping aside : the pin may be now removed
and the rotatory movement of the instrument continued
until the diploe is reached ; this may be ascertained by the
132 OPERATIOX FOR NECROSIS. [chap- ix.
mcdallarj cavity, is to make use of the trephine, in con-
junction with Hey's saw, in the following manner.
Operation for removal of a sequestrum from tfie in"
terior of the shaft of a bone. — To effect this it is generally
necessary to remove a portion of the shaft wall of
the bone. The most subcutaneous part of this being
exposed by an incision shaped | 1 *, the trephine
should be applied at either end of the piece of bone
to be removed, the crown of the instrument being of
the same diameter as the portion of bone; two circular
pieces having been thus removed so as to open the
medullary cavity, a Hey's saw should be used to con-
nect the opposite and external margins of these holes in
the bone, and tlie elevator applied to the portion of the
shaft thus circumscribed : in this way a piece of the shaft
wall may be removed of sufficient size to expose the me-
dullary cavity, and to allow of the extraction of a seques-
trum ; the portion removed will be ) ( sha[)ed.
Again, the interior of the shaft of a long bone may be
exposed by making, with Hey's saw, two longitudinal
incisions parallel with the long axis of the bone, and con-
necting their extremities at either end by dividing the
intervening bone with a chisel and mallet, and thus re-
moving an oblong portion of the shaft wall.
The stomach-pump, — This instrument, for introducing
or withdrawing fluids from the cavity of the stomach,
should always be examined before being used, to ascertain
its mode of action ; all are not precisely alike in the ar-
rangement of their valves : it is therefore advisable, first
to plunge the extremity of the instrument into a basin of
water, and to work the piston up and down once or twice.
* The long limb of this incision should be parallel with the long axis of
the bone.
CHAP. IX.] USE OP THE STOMACH-PUMP. 133
nie operator, being provided with an oesophageal tube,
which must fit the nozzle of the pump, should stand on
the right-hand side of the body, the head of the latter
being slightljr thrown back. Having oiled the extremity
of the tube *, he should place the forefinger of the left hand
into the right-hand angle of the mouth, and depress the
tongue, while with the right hand he should introduce the
tube at the opposite corner of the mouth, pass it straight
back to the posterior wall of the pharynx, and turning the
point downwards, should push it on until, by the length of
tube that has disappeared, it cannot but have entered the
stomach. The end of the tube should now be attached to
the pump, and the extremity of the latter plunged into
water : about a pint having been thrown into the stomach,
the valve may be reversed, and some of it withdrawn, and
this proceeding repeated at the discretion of the operator.
On the living body the reverse action of the instrument —
we mean the drawing of the fluid out of the stomach —
is seldom needed ; it is generally sufficient to shake the
tube in the throat, or to pull it up and down a little. This
will for the most part produce the speedy complete eva-
cuation of the contents of the stomach by vomiting.
* It may be advantageously bent to a small extent, so as to give it a very
gentle curve.
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INDEX.
Amassat's operation, 16.
Allarton, operation of Mr., for litho-
tomy, 57.
Amputations, Chap. VI., p. 60.
general remarks, 61.
instruments required, 63.
Anatomy of phalangeal articulations,
63.
Amputation of last phalanx, 65.
second phalanx, 65.
first finger at metacarpal joint, 67.
second finger at metacarpal joint,
67.
third finger at metacarpal joint,
67.
little finger at metacarpal joint, 68.
fingers, en masse, 68.
third and fourth metacarpal bones,
69.
second and fifth metacarpal bones,
70.
thumb at metacarpophalangeal
joint, 70.
thumb at its carpal joint, 71.
hand at carpo-metacarpal joint, 72.
hand at wrist-joint, by a palmar
flap, 75.
by double flaps, 77.
forearm, circular amputation of,
78.
flap amputation of, 78.
combined method, 80.
Mr. Teale's method, 81.
upper arm, circular amputation of,
81.
flap amputation of, 82.
combined method, 83.
Mr. Teale's operation, 83.
upper extremity at shoulder-joint|
83.
Amputation — continued,
by upper and lower flap?,
by antero-posterior flaps, 85.
removal of the breast, 87.
Amputations of lower extremity, 89.
phalanges of toes, 91.
toes, en masse, 92.
Lisfranc's operation, 93.
Hey's operation, 93;
Chopart's amputation, 96.
Syme's amputation, 97.
Roux's amputation, 98.
Pirogoflf's amputation, 98.
Pirogoff, Dr. Watson's modification
of, 100.
circular, of the leg, 103.
flap, of the leg, 104.
combined method, 104.
Mr. Teale's operation, 105.
flap, at the knee-joint, 106.
circular, of the thigh, 108.
flap, of the thigh, 109.
combined method, 110.
Mr. Teale's method, 1 10.
at hip-joint. 111.
of the penis, 113.
remoTal of testicle, 114.
Anatomy of articulations of the foot, 89.
Aneurism needle, its use, 27.
Ankle-joint, resection of, 126.
amputation at, 97.
Arm, amputation of upper, 81.
Articulations of carpus, 63.
of tarsus, 90.
Artificial anus, operation for, 16.
Assistant, duties of, in tenotomy, 19.
Axillary artery, course of, 32.
ligature of, 33.
Bellocq's cannula, 9.
VMj
INDEX.
Bend of the elbuw, ligature of brachial
at, 31.
Bia'ps ftMnori^, division of, 22.
Blunt-pointed tenotomy knife, use of,
18.
BoHinon's operation on the punctum, 13.
Brachial artery, ligature of, 30.
Brea.st, amputation of, 87.
Butcher, operation of Mr., on wrist-
joint, 119.
Calcis, manner of sawing, in Pirogoflf's
amputation, 100.
Cancfllous ends of bones, perforation of,
134.
Carotid, common course of, 37.
common lipjature of, 38.
external course of, 38.
external ligature of, 39.
internal hgature of, 39.
CarjK)- metacarpal articulations, anatomy
of, 72.
amputations at, 74.
CiLstration, 1 14.
Catheter, Eustachian, 10.
Catheter, for nasal duct, 12.
Circular amputation, 61.
of leg, 103.
of thigh, 108.
Chopart's operation, 96.
Colon, operation for opening, 1 6.
Conjunctiva, division of, in strabismus,
20.
Coecum, operation for opening, 1 7.
Combined method of amputation, 62.
Continuous suture, 7.
Descending colon, Amussat's ojierati(»n,
16.
Director, manner of holding, 5.
for resections, 116.
Disarticulation of shoulder-joint, 83.
of hip-joint, 111. See .Amputa-
tions.
Division of internal rectus, 1 9.
Dixon's operations for removal of eyeball,
15.
Dorsum of foot, ligature of artery on, 47.
Elbow-joint, resection of, 119.
Eustachian tube, orifice of, 11.
catheterisation of, 11.
Ezcittion of testicle, 114.
Explanation of terms employed, 3.
Eyeball, removal of, 15.
Facial artery, ligature of, 41.
Fascia, maimer of opening, 27.
Femoral artery, ligatare of, 45.
anatomy of, 44.
Femur, resection of head, 128.
Furgusson, operation of Mr., on upper
jaw, 125.
Fingers, resection of their joints, 116.
amputation of, 67.
en masse, 68.
Flap amputation, general remarks on, 61.
Flaps, amputation of upper arm by, 82
P'lap operation on leg, 104.
amputation of ihigh, 109.
of forearm, 78.
plantar, manner of forming, 94.
Forearm, amputation of, 77.
Forceps, Mr. Lloyd's, 59.
their use in exposing arteries, 26.
Gouge, use of, on heads of bones, 131.
Great toe, resection of its metatarsal
bone, 126.
Grooved director, its use in exposing
arteries, 26.
H-shaped incision for elbow-joint, 201.
Hamstrings, division of, 22.
Hand, amputation of, at wrist-joint, 75.
Key's amputation, 93.
Hip-joint, amputation at. 111.
Hook, use of, in strabismus, 20.
Humerus, disarticulation of, 83.
Hunter's canal, ligature of femoral in,
45.
Iliac, common course of, 41.
common ligature of, 42.
internal ligature of, 43.
external course of 43.
ligature of, 43.
Illustrations, list of, xi.
Innominate artery, ligature of, 36.
Instruments for ligature of arteries, 26.
for resection, 115.
on the Use of certain, 130.
generally necessary, 1.
for tenotomy, 18.
INDEX.
137
Introduction, general, 1 .
Internal rectus, division of, 19.
Jaw, lower, removal of, 122.
upper, removal of, 124.
Joints of the tarsus, situation of, 90.
Joints, resection of. See Resections.
Knee-joint, amputation at, 106.
resection of, 127.
Knot, manner of tightening it on an
artery, 27.
Knuckles, external anatomy of, 64.
Lachrymal duct, cathetensm of, 1 2.
passages, anatomy of, 13.
Landmarks, points of bone to be selected
as, 25.
Langenbeck's resection of shoulder-joint,
122.
of elbow-joint, 120.
Laryngotomy, 53.
Lateral operation for lithotomy, 54.
Ligaments, method of dividing in Lis-
franc's operation, 93.
Ligature, method of applying it, 27.
of arteries. Chap. IV., p. 25.
general rules, 25—28.
radial, 28.
ulnar, 29.
brachial, 30.
axillary, 31.
subclavian, 33.
innominate, 36.
common carotid, 37.
external carotid, 38.
internal carotid, 39.
lingual, 39.
facial, 41.
temporal, 41.
common iliac, 42.
interaal iliac, 43.
external iliac, 43.
femoral, 44.
anterior tibial, 46.
posterior tibia), 48.
peroneal, 49.
popliteal, 50.
Lingual artery, anatomy of, 39.
ligature of, 40.
Lisfranc's amputation, 93.
Liston's resection of elbow, 120.
Lithotomy, 54.
Longitudinal incision for resecting
shoulder-joint, 122.
Lower jaw, removal of, 122.
Lloyd, operation of Mr., for lithotomy, 58.
Leg, amputation of, 102.
Meatus, nasal, 11.
Metacarpal bone of thumb, resection of,
117.
Metacarpal bones, amputation of 3rd
and 4th, 69.
amputation of 2nd and 5th, 70.
Metatarsal bone of great toe, resection of,
126.
Median operations. Chap. V., 51.
tracheotomy, 52.
laryngotomy, 53.
pharyngotomy, 53.
lithotomy, 54.
lateral operation, 54.
Mr. Allerton's operation, 57.
Mr. Lloyd's operation, 58.
Minor surgery, certain operations in.
Chap. II., 4.
positions of the knife, 4.
sutures, application of, 6 — 9.
plugging the nostrils, 9.
catheterism of Eustachian tube, 10.
catheterism of lachrymal duct, 12.
Mr. Bowman's operation on the
punctum, 13.
excision of the eyeball, 15.
artificial anus, 16.
Needle for quilled suture, 8.
Necrosis, operation for, 132.
Nostrils, section of, 11.
plugging the, 9.
Operations, table of, 2.
Oval, incision, for amputation, 62.
PirogofTs operation, 98.
without disarticulation, 100.
Penis, amputation of, 1 13.
Peroneal artery, ligature of, 49.
tubercle, situation of, 91.
Phalanges of fingers, amputation of, 63.
resection of, 116.
of toes, amputation of, 91.
Pharyngotomy, 53.
Plugging the nares, 9.
138
IXDEX.
1 ■
j
Ping for posterior nares, 9.
Poeitions of knife, 4 — 6.
Popliteal artery, ligatare of, 50.
Pamp, stomach, manner of applying,
132/
Panctum, operation for opening, 14.
Quilled suture, 8*
Radial artery, ligature of, 28.
Bectangular flaps, amputation by general
rules, 62.
Recti muscles, division of, 20.
Roux, amputation of M., 98.
Resections, instruments, 115.
phalanges of fingers, 116.
phalangeal joints, 116.
metacarpal bone of the thumb, 117.
metacarpal bone of little finger, 118.
wrist-joint, 118.
carpal end of the ulna, 119.
elbow-joint, 119.
shoulder-joint, 121.
lower jaw, 122.
upper jaw, 124.
phalanges of toes, 126.
phalangeal joints of toes, 126.
metatarsal bone of great toe, 126.
ankle-joint, 126.
knee-joint, 127.
hip-joint, 128.
Sac, lachrymal, 13, 14.
Saw, method of using on bones of fore-
arm, 78.
Scalenus anticus, ligature of subclavian,
external to, 35.
ligature of subclavian, internal to,
35.
Scalpel, its use in tying arteries, 26.
manner of holding, 4 — 6.
Scaphoid bone, position of, 90.
Sequestrum, removal of, 132.
Semilunar flap for resecting shoulder,
121.
Semitendinosus, section of, 23.
Selection of a subject, I.
Sharp-pointed tenotomy knife, use of,
18.
Shaft, operations for necrosis on shafts
of bones, 132.
Sheath, its separation from a vessel, 27.
Shoulder-joint, resection of, 121.
amputation at, 83.
Skull, application of trephine to, 130.
Speculum, Mr. Lloyd's, 58.
spring wire for strabismus, 19.
Staff, position of, in lithotomy, 55.
Strabismus, operation for, 19.
Stromeyer's resection of shoalder-joint,
122.
Stomach-pump, application of, 132.
Stemo mastoid, division of, 20.
Sutures, 6.
method of applying continuons and
interrupted, 7.
method of applying twisted and
quilled, 8.
Subclavian, course of, 34.
artery, ligature of, 35.
Syme, operation of Mr., at ankle-joint,
97.
Table of operations, 2.
Tarsus, external anatomy of, 90.
Teale, operation of Mr., general descrip-
tion of, 62.
on foreann, 81.
on upper arm, 83.
on leg, 105.
on thigh, 110.
Tenotomy, Chap. III., 18.
general remarks, 18, 19.
strabismus, 19.
stemo mastoid, 20.
tibialis anticus, 22.
hamstrings, 22.
tendo achillis, 23.
tibialis posticus, 24.
Temporal artery, ligature of, 41.
Testicle, removal of, 114.
Thigh, amputation of, 108.
Thumb, use in tenotomy, 19.
amputation of, at metacarpus, 70.
at carpal joint, 71.
resection of its metacarpal bone,
117.
Tibial artery, posterior, ligature of, 48.
anterior, ligature of, 47.
Tibialis anticus, division of, 22.
posticus, division of, 24.
Toes, amputation en masse, 92.
INDEX.
139
Tracheotomy, 52.
Trephine, application of, 130.
Twisted suture, 7.
Ulnar artery, ligature of, 29.
Ulna, resection of carpal end, 119.
Upper jaw, removal of, 124.
Urethra, splitting the orifice of, 114.
Watson's, Dr. E., plan of performing
PirogoflTs amputation, 100.
Wrist-joint, resection of, 118.
amputation of hand at, 75.
Wry neck, operation for, 20.
THE END.
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Buyldon on Valuini; Rents, ftc.
« on Road Leffulation
Caird'a Prairie Fanning
Cecil's Stud Farm .
Hoskyns's Talna
Loudon's AgricQlture .
Low's Elements of Af^ricaltnre
Morton on Landed Estates
«
6
8
8
II
14
14
17
Arts, HanTLfaotnres, and Arcbi-
tectare.
Brande's Dictionarr of Science, ftc. . 8
*' Organic Chemistrj ... 6
Cresy's Civil Engineering ... 8
Fairoaim's Information for Engineers . 9
G wilt's Encyclopedia of Architecture . 10
Harford's Plates from M. Anftelo . . 10
Humphreys's Parables Illuminated . 12
Jameson's Sacred and Legendary Art . 13
'< CommonpUice-Book . .13
K&nig's Pictorial Life of Luther . . 10
Loudfin'rKural Architecture . . . 14
Mac Dougall's Campaigns of Haunibal . 15
•* Theory of War . . 15
Moseley's Engineering . . .17
Piesse's Art of Perfumery ... 18
Richardson's Art of Horsemanship . 19
Scoifem on Projectiles, &c. . . .20
Steam Engine, by the Artisan Club . 6
Ure'sDicUonaryof Arts, Ac. . . 23
Biography.
Araffo's Lives of Scientific Men S
Bain ic's Memoir of Bate . 9
Brialmont's "Wellington .... 6
Biunen's Hippoljtos .... 7
Bunting's (Dr.) Life .... 7
Crot>se's (Andrew) Memorials . 8
Gleig's Essays 10
Green's Princeoses of England . . 10
Harford's Life of MichaelAngelo . . 10
Lardner's Cabinet Cyclopaedia . 13
Marshman's Life of Carey, Marshman,
and Ward 15
Maunder'* Biographical Treasury . 16
Morris's Life of Berket .... 17
Mountain's (Col.) Memoirs . . .17
Parry's (Admiral) Memoirs . . .18
Russell's Memoirs of Moore . . .17
" (Ur.) LifeofMeazofanti. . 20
SchimmelPenninck's (Mrs.) Life . . 20
Southe)'s Life of Wesley ... 21
Steplien's Ecclesiastical Biography . 22
Strickland's Queens of Enguina . . 22
Sydney Smith's Memoirs . . . 21
Symonds's ( Admiral) Memoir* . . 22
Taylor's Loyola 22
•« Wesley 22
Uwino's Memoirs and Correspondence . 23
Waterton's Autobiography and Essays . 24
Books of General Utility.
Acton's Bread- Book . . . . fi
*• Cookery- Book .... 6
Black's Treatise on Brewing ... 6
Cabinet Gazetteer 8
Cust's Invalid's Own Book ! . . 9
Hints on Etiquette H
Hudson's Executor's Guide . . . I2
« on Making Wills ... 12
Kesteven's Domestic Medicine . . 13
Lardner's Cabinet Cyclopedia . . IS
Loudon's Lady's Country Companion . 14
Maunder** Tieasurr of Knowletlge . IS
" Biographical Treasury . 16
'* Geographical Treasury . 16
** Sctentinc Treasury . . 15
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Piesse's Art of Perfumery ... 18
Pitt's How to Brvw Good Beer . . 18
Pocket and the Stud . . . .11
Pycroa's English Reading . . .19
Rich's Companion to Latin Dictionary . 19
Richardson's Art of Horsemanship . 19
Riddle's Latin Dictionaries . . .19
Roget's Knulikh 1 hesaums . . . 20
Rowton's Debater 20
Short Whist 21
Simpson's Handbook of Dining . .21
Thomson's Interest Tables . . .23
Webster's Domestic Economy . . 24
Willich's Popular Tables ... 24
Wilmot's Blackstone ... 24
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Hooker's British Flora .... II
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" Sjnopftis of the British Flora. 14
" Theory of Florticulture . . 14
Loudon's Ilortus Britannicus . .14
" Amateni Gardener . . .14
" Tre.-8 and Shmbs . . .14
" Ganlening . . . .14
** Plants 14
Pereira's Materia Mediea ... 18
Bivers's Rose Amatenr's Guide . 19
Watson's (:>bele Britannica . 24
Wilson's British Mosses .... 24
ChronologT,
Brewer'p Historical Atlas . . •. 6
Tunsen'f Anciunt Ei^ypt ... 7
H.iydn'a Beatfon's Index . . .11
Jaquemet's Two Chronologies . . 13
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Gilbart's LoKic of Baakine ... 10
" Treatise on Banliair . . 10
I^orimer's Young Master Manner . . 14
M'CuUoch's Commerce and Navigatioa 15
Thomson's Interest Table* ... 22
Tooke's History of Prices ... 22
Criticism, History, and Memoirs.
8
7
7
6
8
8
fl
9
10
Brewer's Historical Atlas
Bunsen's Ancient "Etfjjtt
" Hippolytus . . . •
Chapman's Gustavus Adolphns
Connolly's flappers and Miners
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Crowe's History of Franca
Fischer's Francis Bacoa ....
Frazer's Letters during the Peninsular
and Waterloo Campaigns .
Gleig's Essays 10
Gum<?y's Historical Sketches . . 10
Hayward's Eways 11
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Kemble's An«lo-8axons . . . .13
Lardner's Cabinet Cyclomedla . 13
Macaulay'a Critical and Hist. Essays . 14
« History of England . 14
** Speeches .... 14
Mackintosh's Miscellaneous Works . 15
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M'CuIloch's Geographical Dictionary . 15
Maunder's Treasury of History . . 16
Merivale's History of Rome . . .16
" Roman Refmblic . . . 16
Milner's Church History . ... 16
Moore's (Thomas) Memoirs, See. . . 17
Mure's Greek Literature . . .17
Normanby's Year of BerolutinB . . 18
Perry's FranVs 19
Porter's Knights of Malta . . .19
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SchimmelPenninck'sP) inciples ofBeauty 20
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Stephen's Ecclesiastical Biography
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Murray's Encyclopirdia of Geography
Sharp's British Qaxttteer
22
21
21
21
21
22
22
22
23
23
23
23
24
6
7
8
13
15
16
17
21
Jnvenile Books.
Amy Herbert « 20
Cleve Hall 20
Earl's Daugliter (The) .... 20
Experience of Lire 20
Gertrude 20
Howitt's Boy's Countrr Book . 12
" (Mary) ChUdien's Year . . 12
Ivors 20
Katharine Ashton 20
Laneton Parsonage .... 20
Margaret Percival 20
Piesse's Chymieal, Natural, and Pliy<
sical Magie 18
Py croft's Collegian's Guide . . .19
6
7
7
7
8
9
U
11
13
18
19
21
Medidne, Surgery, &o.
Brodie's Psychological Inquiries .
Bull's Hints to Mathers . . • .
'* Management of Children
" Work on BUndnesa
Copland's Dictionary of Medicine .
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" Medical Notes and Reflccti<ms
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Richardson's Cold-water Cure .
Spencer's Principles of Psychology
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Miscellaneous Litcrotnre.
Bacon's (Lord) Works .... 6
Defence of fcJtpM ^JMtik ... 9
De Fonblanque on Army Admin&strati«ii 9
Eclipse of Faith S
Greathed's Letters frosn Ddhi . . lo
Greyvon's Select CorrespMidence . .10
Gumey's Evening Reereations . . lo
Hasfsall's Adulterations Detected, te. . 11
Havdn's Book of Dignities . . .11
Holland's Mental Physiology . . li
Jilnj'i (lonl) EHin .
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^ Sir BsKJUcnr C. Bbodis, Bart.
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